Background: Treatment of high-grade spondylolisthesis remains controversial. In-situ fusion does not address the sagital balance, reduction and fusion on the other hand is associated with unacceptably high rate of neurological complications. Aim: To describe the results of a novel technique using Magerl External Fixateur for gradual reduction followed by circumferential fusion. Methods: From 1988 to 2006, thirteen patients were treated with this technique at our institution. They all had high grade spondylolisthesis. Retrospective case note review and radiographic analysis were carried out. 10 point Visual Analogue Sore (VAS) for pain, Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), SF-36 Health Survey, and Patient Satisfaction Questionnaire were collected. Complete set of data was available for 9 patients, 7 Female and 2 Male. Mean age at operation was 16 years (range 12–22), and average length of follow-up was 11 years (range 5–19). Results: Post operatively, Percentage of Slip was improved by an average of 70%(range 32–96%)(p=0.001), Slip Angle by 72%(p=0.0001) and sacral Inclination by 59%(p=0.0016). Radiological fusion was achieved in all but one. VAS for leg and back pain improved from 8.4 (range 8–9) and 8.2 (range 6–10) to 0.8(range 0–2) and 1.2 (range 0–2) respectively. These improvements were statistically significant (p< 0.001). ODI at the latest follow-up averaged 8% (range 0–16%) and LBOS 56.6 (range 44–70). The mean SF-36 for physical domains was 87.5 (range 80–93) and that for the psychological domains was 91.25 (range 81–100). All patients were fully satisfied. 3 cases had culture negative excessive discharge from one pin site. 2 patients developed transient parasthesia and one patient developed asymptomatic pseudoarthrosis. Conclusion: Our technique albeit in a small cohort of patients, achieved significant correction of the commonly used and widely accepted radiological measurements without any neurological complications. The radiological improvement was also reflected in statistically significant improvement in validated outcome measures

Introduction. Acquired chronic radial head (RH) dislocations present a significant surgical challenge. Co-existing deformity, length discrepancy and RH dysplasia, in multiply operated patients often preclude acute correction. This study reports the clinical and radiological outcomes in children, treated with circular frames for gradual RH reduction. Materials and Methods. Patient cohort from a prospective database was reviewed to identity all circular frames for RH dislocations between 2000–2021. Patient demographics, clinical range and radiographic parameters were recorded. Results. From a cohort of 127 UL frames, 30 chronic RH dislocations (14 anterior, 16 posterior) were identified. Mean age at surgery was 10yrs (5–17). Six pathologies were reported (14 post-traumatic, 11 HME, 2 Nail-Patella, 1 Olliers, OI, Rickets). 70% had a congruent RH reduction at final follow-up. Three cases re-dislocated and 6 had some mild persistent incongruency. Average follow up duration was 4.1yrs (9mnths-11.5yrs). Mean radiographic correction achieved in coronal plane 9. o. , sagittal plane 7. o. and carrying angle 12. o. Mean ulna length gained was 7mm and final ulnar variance was 7mm negative (congenital). All cases achieved bony union with 2 requiring bone grafting. Mean frame duration was 166 days. Mean final range of motion was 64. o. supination, 54 . o. pronation, 2. o. to 138. o. flexion. 5 complications and 7 further operations were reported. Conclusions. The majority of children having frame correction achieve complete correction or minor subluxation, which is well tolerated clinically. Frame assisted reduction is an effective tool for selective complex cases irrespective of the pathology driving the RH dislocation

Aims

To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Aims

To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.

Purpose: To evaluate the changes in lumbar spine kinematics and clinical outcomes of patients with spinal stenosis 2 years after implantation of the X Stop interspinous decompression device. Methods: 10 patients (6 males; 4 females) underwent X Stop procedure. Age ranged from 57 years to 71 years. 15 levels were operated (5 single levels: L. 2-3. - 1, L. 4-5. - 4; 5 double levels: L. 3-4. +L. 4-5. – 4; L. 4-5. +L. 5. S. 1. – 1). A 0.6 Tesla Upright MRI scanner was used to acquire images in seated (flexion, extension, and neutral) and erect postures at preoperative, 6 months, and 2 years after surgery. The total range of motion of the lumbar spine and the operated segments were measured, along with changes in disc height, areas of the exit foramens, and dural sac. Clinical outcomes were assessed by Zurich Claudication Questionnaire before and 3, 6, 12, and 24 months after surgery. Results: Mean Zurich Claudication Scores (n=10). At 6 months, there was a significant increase in the spinal canal and foraminal dimension. However at 2 years there was a reduction in these dimensions such that there was no significant difference from the preop-erative measurements. Conclusion: The results of this prospective observational study indicate that X Stop offers significant short-term improvement. It is a safe, effective, and less invasive alternative for treatment of lumbar spinal stenosis. The maximum clinical benefit and mechanical efficacy seems to be realized in the early stages postoperatively with gradual reduction thereafter over 2 years. Co-existing co-morbidities such as obesity and osteoarthritis in the lower limbs may influence the clinical results

The majority of studies investigating the outcome of lumbar decompression surgery have been retrospective in nature and have not used validated measures of outcome. The aim of this study was to prospectively investigate the short and long term outcome of lumbar decompression surgery in terms of function, disability, general health and psychological well being. Eighty-four patients undergoing lumbar spinal stenosis surgery were recruited into this study. Patients were assessed using validated measures of outcome pre-operatively, and at 6 weeks, 6 months and one year post-operatively. A significant reduction in pain (p< 0.001) was observed at the 6 week post-operative stage, this did not change at the subsequent assessment stages. Only some of the SF~36 categories were sensitive to change. The sub-categories that were sensitive to change were; physical function (p< 0.05); bodily pain (p< 0.001); and social function (p< 0.05). Improvements were observed in these categories at the 6 week and 6 month reviews. A gradual reduction in the Oswestry Disability Index (ODI) was observed with time, with changes principally being observed between the 6 week and 6 month review, and 6 week and one year review stages (p< 0.05). Minimal changes were observed in the psychological assessments with time. The outcome of surgery could not be predicted reliably from psychological, functional or pain measures. Lumbar decompression surgery leads to a reduction in pain and some improvements in function

Purpose: To assess the use of abdominal aorta cryopreserved allografts as guided regeneration membranes in long bone defects. Materials and methods: This is a prospective randomized blind study of 10 White New Zealand rabbits. 10 mm-long diaphyseal defects were created in both radii: on one side the defect was separated from the surrounding tissue by means of a tube-shaped cryopreserved aortic allograft; the contralateral radius (control) was left to develop spontaneously with no membrane. The animals were put down after 6, 12, 24 and 30 months. A whole range of different studies were made: x-rays, CT, MRI, morphodensitometric techniques and optical and electronic microscopy. Results: No complete bone regeneration was observed in any of the controls. In 9 out of the 10 defects for which an aortic allograft was used complete bone regeneration was achieved as well as a restoration of continuity with a corticomedullary pattern. A progressive increase in density and thickness was observed in the regenerated cortex, which reached values similar to those of normal bone. A gradual reduction of the medullary/cortical thickness index was also detected. Discussion: The microscopic images taken suggest that cryopreserved arterial allografts used in guided regeneration behave like barrier membranes and as osteoinductive agents because of the osteoblastic differenciation of endothelial and/or muscular cells and/or ossification secondary to proteic changes in the extracellular matrix of the artery. This could be regarded as the application of artery calcification and ossification (usually associated with arteriosclerosis, ageing, diabetes and renal failure) to the regeneration of bone defects. Conclusions: It is possible to use cryopreserved aortic allografts as osteostimulating membranes in the guided regeneration of bone defects

This study was undertaken to evaluate the efficacy and reliability of posterior intra-operative reduction and fusion by pedicle screw fixation in the treatment of children and adolescents for severe lumbosacral spondy-lolisthesis.Researchers identified 21 patients who underwent reduction of their high-grade spondylolisthesis at our Institution between 1993 and 2000. Recent clinical and radiograph data were available for all patients. Indications for surgery were severe back pain in 21 patients, leg pain in 17, cosmetic appearance in 16 and progression of slippage in 15. There were 11 females and 10 males, aged 16 years on average (range, 11–18 years). Seven patients had grade III slippage, nine grade IV and five grade V. The slippage was at L4-L5 level in one patient and at L5-S1 in the remaining cases. The instrumented levels were 2 (L4-S1) in 12 patients and 1 in nine (L5-S1). The patients underwent surgery using a single posterior surgical procedure. After removal of the loosened arch and complete discectomy, gradual distraction and posterior translation of the anteriorly displaced vertebral body were performed using a temporary device (Harrington rod) placed bilaterally between L1 and the sacral wings. Reduction was followed by a posterior interbody strut graft or placement of titanium cages and pedicle segmental fixation. At a mean follow-up of 5 years (range, 1–10 years) a complete remission of back pain was observed in 18 cases and incomplete in three; all presented solid fusion radiographically. The mean correction of the slippage was 33.1%.(from 78.3% to 41%) and that of the slippage angle 51% (from 35.2° to 17°). Complications included two skin protrusions of a sacral screw, two transitory neurological deficit (L5-S1). Two patients with screw pullout underwent instrumentation revision and reinsertion of screws; another two patients underwent anterior interbody fusion since slippage exceeded 50% after posterior reduction. Reduction of high-grade spondylolisthesis may be considered for patients with a high degree of lumbosacral kyphosis, an unacceptable clinical appearance, and/or neurological deficit. With the advent of pedicle screw fixation, posterior instrumentation and reduction appears feasible. We found that using the gradual reduction by temporary Harrington rod incurs less risk than other options for treating high-grade spondylolisthesis. This procedure provides a controlled method of reduction where continuous visualisation of nerve roots is possible and internal fixation is achieved

The majority of studies investigating the outcome of lumbar decompression surgery have been retrospective in nature and have not used validated measures of outcome. They have rarely gathered any information regarding patient rated expectations of surgery and measures of satisfaction with surgery. The aim of this study was to prospectively investigate the short and long term outcome of lumbar decompression surgery in terms of function, disability, general health and psychological well being and to examine patient expectations of surgery and short and long term satisfaction with the outcome of decompressive surgery. Eighty-four patients undergoing lumbar spinal stenosis surgery were recruited into this study. Patients were assessed using validated measures of outcome pre-operatively, and at six weeks, six months and one year postoperatively. On recruitment into the study patients were also asked to rate their expectations of improvement in pain, general health, function etc. In addition at each review stage patients were asked to rate their satisfaction in improvement of these key outcome measures. A significant reduction in pain (p< 0.001) was observed at the six week post-operative stage, this did not change at the subsequent assessment stages. Only some of the SF~36 categories were sensitive to change. The sub-categories that were sensitive to change were; physical function (p< 0.05); bodily pain (p< 0.001); and social function (p< 0.05). Improvements were observed in these categories at the six week and six month reviews. A gradual reduction in the Oswestry Disability Index (ODI) was observed with time, with changes principally being observed between the six week and six month review, and six week and one year review stages (p< 0.05). Minimal changes were observed in the psychological assessments with time. The outcome of surgery could not be predicted reliably from psychological, functional or pain measures. The results also demonstrated that patients had very high expectations of recovery particularly in terms of pain and function and that patients were confident of achieving this recovery (76.8%) confident of a good result. Levels of satisfaction however, varied considerably. 41% of subjects were 50% satisfied with the outcome, whilst 30% were dissatisfied. Most patients felt that they had made the right decision to have surgery although the surgery had only achieved 43.4% ± 37.8 of the outcome they had expected. In conclusion, lumbar decompression surgery leads to a reduction in pain and some improvements in function. Examination of patient’s expectations of and satisfaction with surgery revealed that frequently patients had unrealistic expectations of their surgery and as a consequence tended to have lower levels of satisfaction

Aims

To provide normative data that can assess spinal-related disability and the prevalence of back or leg pain among adults with no spinal conditions in the UK using validated questionnaires.

Aims

When the present study was initiated, we changed the treatment for late-detected developmental dislocation of the hip (DDH) from several weeks of skin traction to markedly shorter traction time. The aim of this prospective study was to evaluate this change, with special emphasis on the rate of stable closed reduction according to patient age, the development of the acetabulum, and the outcome at skeletal maturity.

We present in this study our experience in wide decompression, gradual acute reduction and fusion performed in a single sitting, for high grade spondylolisthesis in 17 adolescent cases. Between 1994 and 2005 we undertook surgical management of 17 adoloscents with high dysplastic Spondy-lolisthesis. All our patients were young females except for one with average age of 13.9 years. All of our cases involved the lumbosacral junction. 8/14 cases presented with frank spondyloptosis (Grade5). Of the remaining 9 cases, 5/14 cases were grade4 and 4/14 were grade3 dysplastic spondylolisthesis respectively. Our indication for surgery in all these patients was unremitting back pain, radicular pain, abnormal posture, gait abnormalities and progressive slip. All these patients underwent single stage wide decompression, posterior instrumentation and reduction of the slips and postero lateral fusion. Since 1999 in addition to the above we routinely performed inter body fusion with cages in lumbosacral segment (9/17 cases). All patients’ spondylolistheses were reduced to < grade2.16/17 of our patients had a very satisfactory outcome. Our average follow-up of these patients is 4 years (range 1–9 years).4/17 of our patients developed some dorsiflexion weakness postoperatively and all recovered within 3 months of operation.1 patient developed deep postoperative infection necessitating the removal of the implant. We conclude that acute correction of high grade spondylolisthesis is a demanding procedure. The newer instrumentation (improved sacral fixation) made reduction less difficult and the final outcome is highly satisfying for the patient and the surgeon

What was the question? The treatment of multi-injured patients requires initial stabilization of general conditions and vital parameters. The first stage in orthopedic management of the fractures in trauma involves stabilization of the bone segments to reduce blood loss and allow nursing. External fixators are fast, versatile and essential in the emergency situation in cases of multiple fractures, especially with soft tissue loss. According to damage control orthopedics (DCO) concepts, it is possible to replace an external fixator (EF) with internal synthesis (ORIF) after a period of time to reduce the risks of ORIF. However, surgery can be difficult to perform and pin sites can be the source of bone infection, in which the EF as a definitive treatment option may be considered. How did you answer the question? In trauma surgery, instability of the hardware, fractures near the joint, frame extending across the knee and the ankle, initial fixation was converted to definitive treatment with circular frames according to the Ilizarov method. Fourteen patients (2 female and 12 males; age 24 to 80 yrs, average age 43,4 y/o) were treated with various circular framses as definitive treatment: Ilizarov (2), Sheffield (7), Taylor Spatial Frame (TSF) (4) and TrueLok (1) between November 2002 and December 2007 in multiply injured patients with ISS > 20. Seven cases were femoral and seven tibial. The femoral group had four knee spanning fixator configurations and three unilateral external fixators. The tibial group had 4 unilateral frames, 1 hybrid EF, 1 across the knee EF and 1 across the ankle EF. Five patients had temporary femoral and tibial hardwares in the same side. Three patients had unilateral tibial and femoral fractures. What are the results? All patients achieved consolidation. The mean duration of femoral EF was 7.6 months (5–9 months). One bone loss in a distal femoral shaft treated with Sheffield EF had lengthening (5 cm) after acute short-hening. Two patients had a gradual distal femoral fracture reduction and a mechanical axis correction by TSF. Three patients with tibial bone loss had 2 trifocal bone transport (17,5 and 9 cm) and 1 bifocal bone transport 5 cm. The TSF had no additional pre-operative planning and major post-operative frame adjustments. The intra-operative devices was easier for the TSF. What are your conclusions? Circular frame osteosynthesis following initial EF, is a reliable and effective strategy for treatment in severe open femur and tibia fractures and post traumatic reconstruction

Treatment for developmental dysplasia and dislocation of the hip (DDH) presenting after one year of age is controversial. There are advocates of both open and non-operative reduction. Surgeons advocating open reduction believe in excising the obstructing soft tissues for all such cases. Others reducing non-operatively suggest that pressure from a reduced femoral head provides gradual concentric reduction with remodelling of the restraints. MR images of hips in a group of patients treated non-operatively were examined to determine the long-term development of the soft tissue around the hip. We have been treating late presented DDH by graduated traction and gentle manipulation under general anaesthetic since 1975. 10 (12 hips) of these patients were consented to have an MRI Scan of their hips. Mean age of presentation was 17 months (13–36 months). Mean follow up was 16 years (7–26 years). Mean duration of traction was 31 days (16–45 days). None of the hips had an open reduction. Subsequently 3 hips had a femoral osteotomy at a mean age of 5. 9 years (4. 1–7. 8) and 3 hips underwent a Salter-type osteotomy at a mean age of 4. 3 years (3. 7–5. 4). According to the grading of Barrett et al, 9 hips were graded clinically excellent, 2 were good and 1 hip was fair. The latest radiological result was graded according to Severin. There were 9 grade 1 hips, 2 grade II hips and 1 grade III. All the patients had coronal, sagittal and transverse scans of both their hips. All the MRI Scans showed a good coverage of the femoral head. Anterior and posterior acetabular cover was adequate in all the hips. Osseo-cartilaginous extension beyond the acetabular margin was constantly found in all the hips. Even in the hip with a Severin score of III, the cartilaginous acetabular extension produced a concentric hip joint. The anterior and the posterior labrum were found to be well developed in all the hips. None of the hips showed any evidence of inverted limbus. 3 hips showed mild evidence of avascular necrosis but there was no evidence of collapse or flattening. Thinning of the articular cartilage was seen in 3 hips but no mechanical changes observed. Capsule and ligamentum teres were found to be well developed and non-obstructive. Long-term results of non-operative treatment of late presented DDH have been found to be satisfactory. The MRI scans have shown an excellent soft tissue remodelling around the hip. Soft tissue restraints preventing initial reduction in late-presented DDH are therefore not an absolute indication for open exploration. MRI scans were found to be an excellent tool to study the effect of soft tissue remodeling in such cases

Objectives

We have observed clinical cases where bone is formed in the overlaying muscle covering surgically created bone defects treated with a hydroxyapatite/calcium sulphate biomaterial. Our objective was to investigate the osteoinductive potential of the biomaterial and to determine if growth factors secreted from local bone cells induce osteoblastic differentiation of muscle cells.

This review explores recent advances in fixator design and used in contemporary orthopaedic practice including the management of bone loss, complex deformity and severe isolated limb injury.